Evaluation of Retinal Disorders During Pregnancy

Pregnant patients are “high-risk” for eye doctors.  Evaluation and treatment of pregnant patients could theoretically place a fetus at risk and care must be taken when evaluating and managing these patients.  Here we review some of the special considerations we must take in the evaluation and treatment of retinal disorders during pregnancy.

Dilation

There are medical-legal concerns when dilating the pregnant patient due to potential systemic effects on the fetus.  Signs and symptoms of retinal disease or indications for retinal examination (eg, diabetes) should be present.  Dilation with Tropicaminde 1% alone is considered safe and effective.  More potent, longer acting cycloplegic agents (e.g., cyclogel and atropine) are not recommended although the risk is considered low.  Phenylephrine is relatively contraindicated since it may elevate systemic blood pressure or cause arterial constriction; of note, studies argue that a concentration of 2.5% does not have a measurable effect on the systemic circulation. 

Diabetic Retinopathy

Pregnancy can precipitate the onset of diabetes (“gestational diabetes”) as well as accelerate the progression of complications in diabetic patients, including retinopathy and nephropathy.  It is critical to evaluate pregnant diabetic with dilated exams on a frequent basis up to once a month depending on the patient’s retinal status.  The presence of any-retinopathy before pregancy, a HgA1C above 7.0 and recent improvement in HgA1C by more than 1.0 all increase the risk of rapid progression.  Early, prompt and aggressive laser treatments are advisable for most patients with macular edema and advanced non-proliferative or early proliferative diabetic retinopathy.

Macular disorders

Macular disorders such as epiretinal membranes, idiopathic choroidal neovascularization, central serous retinopathy and macular hole do occur during pregnancy.  Patients often present with blurred or distored central vision.  Testing with OCT images, visual fields and fundus photos should be considered while fluorescein angiography should be avoided.  Management is more complicated – anti-VEGF therapies such as Avastin and Lucentis are contraindicated since these drugs may enter the systemic circulation and threaten fetal development.  Intravitreal steroids and even surgical removal of choroidal neovascular membranes in select patients may be considered.  For central serous retinopathy (CSR), reducing stress is critical.  Hypertension related serous retinal detachment with pre-ecclampsia or ecclampsia must be ruled out and may present like CSR.  Macular holes can progress during pregnancy and surgery during the second trimester is considered reasonably safe and effective but should be cleared with the OB doctor (see figure 1).  

PVD, Retinal tears and Retinal Detachment

Patients with floaters, flashing lights or loss of peripheral vision require a dilated exam.  Retinal tears and detachments should be treated promptly with care taken to minimize systemic exposure to certain anesthetic agents.  Pneumatic retinopexy with cryotherapy in the office using appropriate local anesthesia is considered safe and effective although fetal monitoring should be considered and head positioning may limit which patients are amenable to this approach.  Conventional laser for retinal tears is considered safe and effective and may be performed in the office.   

The most common retinal complications during pregnancy are progressive diabetic retinopathy, exudative retinal detachments from pre-ecclampsia and macular leakage from CNV as well as CSR.  Prompt evaluation of pregnant patients with a dilated exam can be performed safely and evaluation and treatment should be tailored to the pregnant woman using non-invasive tests such as an OCT.  Laser, medical therapies and even surgery may be undertaken safely and effectively when deemed necessary.  Informed consent tailored to the pregnant female is warranted in each case. 

Ron P. Gallemore, M.D, Ph.D.

Founder and Director

Retina Macula Institute and the

Retina Macula Research Center

South Bay 310-944-9393

Los Angeles 310-466-9393